Utilization Management RN Reviewer

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.   

Utilization Management (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient’s hospital stay or visit. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects.  

This remote role is limited to Florida, Ohio, and Nevada. Candidates must live within one hour of a Cleveland Clinic hospital to be eligible.

A caregiver who excels in this role will:

• Recommend resource utilization.  

• Prioritize and organize work to meet changing priorities.  

• Utilize analytical abilities required to gather data.  

• Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively. 

• Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement. 

• Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan. 

• Achieve a minimum of 85% on IRR quarterly. 

• Complete utilization management for assigned patients with at least 25-30 reviews per day. 

• Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays. 

• Document appropriately in UM notes to provide evidence that the UR process for the case was followed. 

• Attend all staff meeting when scheduled to work. 

• Other duties as assigned. 

Minimum qualifications for the ideal future caregiver include:  

• Graduate of an accredited school of nursing
• Current state licensure as a Registered Nurse (RN)  

• Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross 
• Three years of equivalent full-time clinical experience as a Registered Nurse
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes
• Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution
• Basic knowledge of medical records coding standards
• Awareness of licensing and accreditation standards
• Proficient with Microsoft Office
• Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings.
• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets
• Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures
• Knowledge of and ability to use multiple Hospital information systems and Department's software
• Ability to use copier, fax machine and personal computer

Preferred qualifications for the ideal future caregiver include: 

• Bachelor of science in nursing (BSN)  

• Case Management Certification (CCM) preferred within first year of eligibility
• Prior Utilization Management experience
• Case management or ED experience
• Emergency room experience

• Requires walking, sitting, and/or standing for long periods of time.
• Requires constant attention to detail, reading of medical records, and meeting deadlines.
• Works in an environment where there is some discomfort due to dust, noise, temperature.

• Follows standard precautions using personal protective equipment.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic is pleased to be an equal employment opportunity employer.